SYNDROMS OF HYPERGLYCEMIA AND HYPOGLYCEMIA LECTURE IN INTERNAL MEDICINE PROPAEDEUTICS

Transcription

1 2017/2018 Spring Semester SYNDROMS OF HYPERGLYCEMIA AND HYPOGLYCEMIA LECTURE IN INTERNAL MEDICINE PROPAEDEUTICS M. Yabluchansky L. Bogun, L.Martymianova, O. Bychkova, N. Lysenko, M. Brynza V.N. Karazin National University Medical School Internal Medicine Dept.

2 reminder: how does endocrine pancreas work

3 reminder: the primary functions Production of pancreatic hormones by three cell types: Glucagon by alpha cells; Insulin by beta cells; Somatostatin by delta cells Hormones travel through the bloodstream to target tissues At the target cells, hormones bind specific receptors and cause cell changes that control metabolism

4 reminder: insulin & glucagon in glucose metabolism regulation _ PNG

5 reminder: structure & roles of insulin 1 Insulin is a polypeptide hormone, composed of two chains (A and B) Both chains are derived from proinsulin (prohormone) Chains are joined by disulfide bonds

6 reminder: structure & roles of insulin 2 Acts on tissues to increase uptake of glucose and amino acids Increases glycogen production (glucose storage) in the liver and muscle Stimulates lipid synthesis from free fatty acids and triglycerides in adipose tissue Also stimulates potassium uptake by cells (role in potassium homeostasis)

7 reminder: insulin secretion control mechanisms 1 Chemically high levels of glucose and amino acids in the blood Hormonally beta cells are sensitive to several hormones that may inhibit or cause insulin secretion Neurally stimulation of the parasympathetic nervous system causes insulin to be secreted _ PNG

8 reminder: insulin secretion control mechanisms 2 Insulin secretion is decreased by decreased glucose and increased insulin concentration in blood and sympathetic stimulation Insulin transported through the blood to target tissues where it binds to target cells specific receptors and acts as a biochemical signal to the inside of the cell: cell metabolism is stimulated _ PNG

9 reminder: blood fasting glucose levels The normal range - a narrow range of about 3.9 to 5.5 mmol/l (as measured by a fasting blood glucose test) Hyperglycemia - high levels Short term (physiological, pathological) Persistent impaired pre-diabetes high - esp. diabetes mellitus (DM) Hypoglycemia - low levels

10 reminder: purpose General evaluation of health Diagnosis of disease or disorders of endocrine pancreas Diagnosis of other systemic diseases that affect endocrine pancreas

11 history-taking: patient s interviewing gathering of information patient s narrative biomedical perspective psychosocial perspective context

12 clinical monitoring diabetic complications Clinical Tests Blood pressure Eye exam Foot exam Management; monitor hypertension and thus risk of heart disease Management; monitor onset and progression of eye disease Management; monitor onset and progression of nerve disease and peripheral arterial disease

13 patient's laboratory examination: indications for testing 1 The American Diabetes Association (ADA) recommendations: Obesity (BMI >25 kg/m 2 ) consider testing to detect pre-dm and type 2 DM in asymptomatic people Family history of DM in first- or second-degree relative

14 patient's laboratory examination: indications for testing 2 The American Diabetes Association (ADA) recommendations: Signs of insulin resistance or conditions associated with insulin resistance (e.g., acanthosis nigricans, hypertension, dyslipidemia, low birthweight) Maternal history of DM or gestational diabetes mellitus (GDM) during gestation

15 patient's laboratory examination: diabetes panel 1 Complete Blood Count (CBC) Glucose, Serum (Fasting) Oral glucose tolerance test (OGTT) Random blood glucose Islet cell antibody test (for type 1 diabetes) Hemoglobin A1c (glycated haemoglobin) Diabetic Urinalysis

16 patient's laboratory examination: diabetes panel 2 The current WHO diagnostic criteria for diabetes should be maintained fasting plasma glucose 7.0mmol/l (126mg/dl) or 2 h plasma glucose 11.1mmol/l (200mg/dl HbA1c 6.5% = diabetes mellitus, HbA1c 5.7 to 6.4% = pre-diabetes or at risk of diabetes Glycated haemoglobin - HbA1c - reflects average plasma glucose over the previous 2 3 months in a single measure which can be performed at any time of the day and does not require any special preparation such as fasting

17 patient's laboratory examination: diagnostic significance of glucose and glycated haemoglobin concentrations Individuals Suitable for Testing Non-pregnant individuals with diabetes risk factors or age 45 years and pregnant women with risk factors (first prenatal visit) All pregnant women (24-28 weeks of gestation) Marker FPG 2-h OGTT (75 g) HbA1c FPG 2-h OGTT (75 g) HbA1c 2-h OGTT (75 g) Fasting 1 h 2 h Clinically Significant Level 126 mg/dl 200 mg/dl 6.5% mg/dl mg/dl 5.7%-6.4% 92 mg/dl 180 mg/dl 153 mg/dl Interpretation Diabetes Increased risk for diabetes Gestational diabetes FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; HbA1c, hemoglobin A1c.

18 patient's laboratory examination: diabetic urinalysis 1 Glucosuria can be detected when level of blood glucose exceeds more than 11 mmol/l Urine tests can t be used to alone to confirm the diagnosis of diabetes mellitus They are ordered more often when there is suspicition on type 1 diabetes Laboratories can test urine for ketone bodies

19 patient's laboratory examination: diabetic urinalysis 2 The body produces ketone bodies when fat tissue is used for energy instead of blood sugar If ketone bodies are present in the urine, this could indicate the high level of glucose in blood with insufficient level of insulin production

20 Endocrine pancreas Glucose Meters Implantable

21 Endocrine pancreas Continuous Glucose Monitors (CGMs) Implantable Continuous glucose monitors (CGMs)contain subcutaneous sensors that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling

22 high level persistent hyperglycemia (DM): types 1 DM type 1 results from the body's failure to produce enough insulin Main risk factors: viruses and toxins that can affect genetically determinated antigens of HLA system and cause autoimmune destruction of beta cells in the islets of Langerhans

23 high level persistent hyperglycemia (DM): types 2 DM type 2 begins with insulin resistance, a condition in which cells fail to respond to insulin properly As the disease progresses a lack of insulin may also develop This form was previously referred to as "non insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes The primary cause is excessive body weight and lack of exercise

24 high level persistent hyperglycemia (DM): types 3 Gestational diabetes, is the third main form and occurs when pregnant women without a previous history of diabetes develop a high blood glucose level

25 high level persistent hyperglycemia (DM): classic & other clinical symptoms 1 Classic Polyphagia (increased hunger) Polyuria (frequent urination) Polydipsia (increased thirst)

26 high level persistent hyperglycemia (DM): classic & other clinical symptoms 2 Other Blurred vision Fatigue Weight loss Poor wound healing (cuts, scrapes, etc.) Dry mouth Dry or itchy skin

27 high level persistent hyperglycemia (DM): early & later clinical symptoms 3 Other Impotence (male) Recurrent infections such as vaginal yeast infections, groin rash, or external ear infections (swimmers ear)

28 Early Endocrine pancreas high level persistent hyperglycemia (DM): early & later clinical symptoms 1 Frequent urination Increased thirst Blurred vision Fatigue Headache

29 high level persistent hyperglycemia (DM): early & later clinical symptoms 2 Later (ketoacidosis) Fruity-smelling breath Nausea and vomiting Shortness of breath Dry mouth Weakness Confusion, Coma Abdominal pain

30 high level persistent hyperglycemia (DM): early & later clinical symptoms 3

31 high level persistent hyperglycemia (DM): early & later clinical symptoms 4

32 high level persistent hyperglycemia (DM) acute complications: diabetic ketoacidosis 1 A potentially life-threatening complication happens in pts DM 1, it can occur in those with DM 2 The symptoms usually evolve over the period of about 24 hours Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production, and abdominal pain Breathing becomes labored and of a deep, gasping character (Kussmaul respiration)

33 high level persistent hyperglycemia (DM) acute complications: diabetic ketoacidosis 2 In severe cases there may be confusion, lethargy, stupor, coma On physical examination there is evidence of dehydration (tachycardia, low blood pressure), "ketotic" odor, and death Blood analysis will reveal significant decreased ph < 7.30 mmol/l Urine analysis will reveal significant levels of ketone bodies, often before other overt symptoms

34 high level persistent hyperglycemia (DM) acute complications: nonketotic hyperosmolar state 1 An acute complication sharing many symptoms with diabetic ketoacidosis, but an entirely different origin Water osmotically drawn out of cells into the blood The kidneys eventually begin to dump glucose into the urine Serum ph >7.30, bicarbonate >15 meq/l, small ketonuria and absent-to-low ketonemia (<3 mmol/l)

35 high level persistent hyperglycemia (DM) acute complications: nonketotic hyperosmolar state 2 Increased risk of blood clot formation If fluid is not replaced, the osmotic effect of high glucose levels, combined with the loss of water, will eventually lead to dehydration Some alteration in consciousness, lethargy may ultimately progress to a coma

36 high level persistent hyperglycemia (DM) acute complications: coma 1 A life-threatening DM complication that causes unconsciousness Three different types : Severe low blood sugar in a DM person Diabetic ketoacidosis advanced enough to result in unconsciousness from a combination of a severely increased blood sugar level, dehydration and shock, and exhaustion

37 high level persistent hyperglycemia (DM) acute complications: coma 2 Three different types : Hyperosmolar nonketotic coma in which an extremely high blood sugar level and dehydration alone are sufficient to cause unconsciousness Diabetic coma was a diagnostic problem before the late 1970s, when glucose meters and rapid blood chemistry analyzers became universally available in hospitals

38 high level persistent hyperglycemia (DM) acute complications: hypoglycemia 1 A medical emergency that involves an abnormally diminished content of glucose in the blood Symptoms hypoglycemia usually do not occur until 2.8 to 3.0 mmol/l Adrenergic manifestations: shakiness, anxiety, nervousness, palpitations, tachycardia, sweating, pallor, coldness, clamminess, mydriasis

39 high level persistent hyperglycemia (DM) acute complications: hypoglycemia 2 Glucagon manifestations: hunger, nausea, vomiting, abdominal discomfort, headache Neuroglycopenic manifestations: abnormal thinking, depression, crying, exaggerated concerns, paresthesia, negativism, emotional lability, fatigue, weakness, apathy, lethargy, daydreaming, confusion, amnesia, blurred vision, automatic behavior, difficulty speaking, incoordination, motor deficit, paresthesia, headache, stupor, coma, etc.

40 Microvascular Endocrine pancreas high level persistent hyperglycemia (DM): chronic complications 1 Diabetic cardiomyopathy Diabetic nephropathy Diabetic neuropathy Diabetic retinopathy Diabetic encephalopathy

41 Macrovascular Endocrine pancreas high level persistent hyperglycemia (DM): chronic complications 2 Coronary artery disease Diabetic myonecrosis Peripheral vascular disease Stroke

42 Other Endocrine pancreas high level persistent hyperglycemia (DM): chronic complications 3 Gastrointestinal (gastroparesis, diarrhea) Genitourinary (uropathy/sexual dysfunction) Dermatologic Infectious Cataracts Glaucoma Periodontal disease

43 high level persistent hyperglycemia (DM): main chronic complications

44 high level persistent hyperglycemia (DM): main chronic complications Diabetic retinopathy results in scattered hemorrhages, yellow exudates, and neovascularization This patient has neovascular vessels proliferating from the optic disc, requiring urgent panretinal laser photocoagulation

45 hypoglycemia (DM) Low blood sugar is common in patients with DM, but most cases are mild and are not considered medical emergencies Effects can range from feelings of unease, sweating, trembling, and increased appetite in mild cases to more serious issues such as confusion, aggressiveness, seizures, unconsciousness, and (rarely) permanent brain damage or death in severe cases

46 hypoglycemia (DM)